The awarding of honors to medical clerks. Results of a national survey.

We conducted a national survey of medical schools to determine the frequency of the awarding of honors to third-year clinical clerks and fourth-year subinterns in internal medicine. Of 126 schools surveyed, 86.5% responded. Of those responding, 66% award honors to their junior clerks and 47% award honors to their fourth-year students rotating on the internal medicine service. Consistent criteria do not exist among programs and even within some programs for such awards. The number of students receiving the awards or the percentage of the class that is felt to qualify for honors is also highly variable. The attainment of honors is an important criterion for residency selection as well as a positive predictor of future performance of candidates. The writing of the dean's letter, residency selection, and the date of the National Residency Matching Program results announcement are now occurring later in the academic year than previously, thus making the results of the fourth-year medicine rotations available to residency selection committees by the time choices have to be made. We conclude, therefore, that it seems useful for all medical schools to award honors not only to third-year clerks but also to senior students.

Spectrum of diseases for resident education in internal medicine.

We examined the spectrum of diseases to which medical residents were exposed in a fully integrated residency program comprised of a voluntary and a municipal acute-care hospital. Although circulatory disorders and diseases of the respiratory and nervous systems accounted for the majority of cases, a broad spectrum of diseases was present for residents' training at both institutions. These observations must be considered within the context of the changing nature of medical practice in the United States, with a marked shift from inpatient to outpatient and office medical care.

Service vs education in internal medicine residency. Need for a resolution.

Decreased availability of internal medicine residents for inpatient care may result from efforts to contain rising health costs and to decrease funding for graduate medical education. The movement toward increased ambulatory training, reduced work hours for residents, and the declining interest in internal medicine careers will further decrease resident numbers. Hospitals have relied on trainees for an extraordinary range of hospital services, resulting in long duty weeks, assumption of large amounts of ancillary responsibilities, excessive patient loads, and increased house staff stress. Residents must be relieved of time-consuming, nonmedical chores and internal medicine training must be redefined to provide experiences which are important to gain competence. Hospitals must find other resources for providing patient care functions not educationally valid for residents, to allow that training to refocus on the appropriate development of the internist of the future.

Empty sella turcica in intracranial sarcoidosis. Pituitary insufficiency, primary polydipsia, and changing neuroradiologic findings.

A 37-year-old man with visual loss was found to have hypopituitarism and primary polydipsia associated with sarcoidosis. Neuroradiologic studies demonstrated a dramatic evolution of CNS lesions, including a left thalamic infarct, an enhancing suprasellar mass, and ultimately an empty sella turcica. The patient has been clinically stable in spite of these changes. This case is likely to be the first reported of CNS sarcoidosis with an empty sella turcica documented by computed tomography.

Cortisol binding in uremic plasma. I. Absence of abnormal cortisol binding to cortisol binding to corticosteroid-binding globulin.

Increased morning plasma free cortisol levels have been reported previously in chronic renal failure (CRF) patients. To see whether binding abnormalities of plasma proteins contributed to the increase in morning free cortisol, binding characteristics of corticosteroid-binding globulin (CBG) were studied in pooled plasma from CRF patients and normal subjects. Using an isocolloidosmolar equilibrium dialysis method the unbound, albumin-bound, and CBG-bound fractions of plasma cortisol were measured within the physiologic range of plasma cortisol levels. Cortisol binding to CBG was equal in uremic and nonuremic plasma as determined by the affinity constants and the binding capacities of CBG for cortisol. In addition, the distribution of cortisol binding was identical in uremic and in nonuremic plasma samples at equal total cortisol concentrations. By confirming that cortisol binding properties of CBG are unaltered in CRF patients, these data support the assertion that elevated morning free cortisol levels in CRF patients are probably due to increases of plasma total cortisol.

Cortisol binding in uremic plasma. II. Decreased cortisol binding to albumin.

We measured cortisol binding to albumin in uremic plasma during a study to see if increased morning plasma free cortisol values, reported previously in chronic renal failure patients, could be explained by binding abnormalities of plasma proteins. Cortisol binding was measured in plasma from chronic renal failure patients and compared to values in normal controls. The unbound and albumin-bound fractions of plasma cortisol were determined using an isocolloidosmolar equilibrium dialysis method and heat inactivation of corticosteroid-binding globulin. A lower ratio of albumin-bound cortisol to unbound cortisol was seen in uremic than in nonuremic plasma (p less than 0.05). This difference was eliminated when uremic plasma was treated with dextran-activated charcoal. These studies suggest that cortisol binding to albumin is decreased in uremic plasma because of a heat-stable substance which is removed from plasma by charcoal treatment.

Modulation of pituitary-adrenocortical function: decreased secretory episodes and blunted circadian rhythmicity in patients with alcoholic liver disease.

Twenty-four-hour episodic secretion of cortisol was studied in patients with chronic alcoholic liver disease in order to define how and if feedback inhibition of the hypothalamic-pituitary-adrenocortical axis had occurred. The patients had prolonged disappearance rates of endogenous cortisol and corticosteroid-binding globulin-binding capacity was low. Multiple sampling (every 20 min) for levels of free and total plasma cortisol was carried out. Mean 24-h total and free plasma cortisol levels were not significantly different from normal, although the mean percentage of free cortisol was high. Cortisol secretion was decreased, as judged by urinary free cortisol values and the percentage of time that secretory activity occurred. Circadian rhythmicity of plasma cortisol levels appeared to be normal, but the amplitude of rhythmicity was decreased. Modulation of cortisol secretion in liver disease patients was shown by fewer secretory peaks and decreased secretory time during 24-hr studies. In the subjects studied, the numbers of secretory episodes and the duration of secretory time correlated positively with levels of corticosteroid-binding globulin and negatively with the half-time of cortisol in plasma. These studies suggest that feed-back inhibition modifies bot the frequency and the amplitude of cortisol secretion in patients with liver disease while the underlying circadian rhythm is preserved.

Pituitary-adrenocortical function in chronic renal failure: blunted suppression and early escape of plasma cortisol levels after intravenous dexamethasone.

The response to iv dexamehasone was studied in patients with chronic renal failure in whom resistance to suppression of plasma cortisol levels after oral steroid had been reported previously. One milligram of dexamethasone was given iv at 2300 h, and plasma cortisol levels were measured every 20 min between 0500-1000h in patients with renal failure, normal controls, and patients with pituitary-dependent Cushing's syndrome. Normal subjects showed a decrease in mean plasma cortisol levels to less than 3 micrograms/dl; patients with Cushing's syndrome showed no suppression of cortisol secretory activity during the sampling period. In renal failure patients, morning cortisol levels fell to values lower than those achieved when the 1-mg dose was given orally or when the steroid was not given, but did not suppress to the levels seen in normals. Early resumption of cortisol secretion occurred in four of five renal failure patients during the 6-11 h after dexamethasone administration. These studies show that iv dexamethasone is more effective than the oral steroid in suppressing pituitary-adrenocortical activity in renal failure patients. However, the incomplete suppression and early resumption of cortisol secretion which are present in chronic renal failure patients even after iv dexamethasone support the suggestion that they have disordered feedback control of the hypothalamic-pituitary-adrenocortical axis.

A variant of adrenomyeloneuropathy with hypothalamic-pituitary dysfunction and neurologic remission after glucocorticoid replacement therapy.

Adrenomyeloneuropathy is a syndrome comprising spastic paraparesis, polyneuropathy, primary adrenocortical insufficiency and variable hypogonadism. We describe a 32 year old man who presented with contractures, peripheral neuropathy, primary adrenocortical insufficiency adn secondary hypogonadism. Abnormal responses of growth hormone, gonadotropins, prolactin and thyrotropin to provocative stimuli were found, without radiographic evidence of a pituitary or hypothalamic lesion. Almost complete recovery from the neurologic abnormalities occurred with glucocorticoid replacement therapy. The clinical features of this patient support a diagnosis of adrenomyeloneuropathy. The hypothalamic-pituitary dysfunction extends the clinical features of this patient support a diagnosis of adrenomyeloneuropathy. The hypothalamic-pituitary dysfunction extends the clinical spectrum of this disease. Remission of the paraparesis coincident with glucocorticoid replacement has not been reported previously.

Endocrine studies in a patient with functioning adrenal rest tumor of the liver.

We report a case of a calcified liver tumor in a 23 year old female patient who presented with virilization and a mild degree of Cushing's syndrome. Androgen levels were elevated; there was loss of cortisol circadian rhythm and marked increase in urinary 17-ketogenic and 17-ketosteroids which failed to suppress with administration of dexamethasone. Venous sampling by inferior vena cava catheterization showed that the highest steroid hormone levels were in blood from the right hepatic vein. After death, in vitro studies revealed that the tumor contained testosterone and cortisol as determined by immunofluorescence techniques. The adrenals and ovaries were atrophic. Results of metyrapone testing indicated dyshormonogenesis. To our knowledge, this is the first case of an adrenal rest tumor of the liver proved to be functionally active.

Pituitary-adrenocortical function in chronic renal failure: studies of episodic secretion of cortisol and dexamethasone suppressibility.

Pituitary-adrenocortical function was studied in patients with chronic renal failure (CRF) and compared with that in normal subjects. All CRF patients were on chronic hemodialysis. The mean morning plasma total and free (nonprotein bound) cortisol levels were higher in patients with CRF. Episodic secretion of cortisol was studied in plasma sampled every 20 min for 24 h. CRF patients demonstrated normal circadian rhythmicity, as evidence by times of peak secretory activity and number of peaks per 24 h. Mean 24-h plasma total cortixol levels were twice the normal levels in CRF patients. Nine of 10 patients with CRF did not suppress plasma total cortisol levels with 1 mg dexamethasone. Four of 10 patients with CRF suppressed with 2 mg dexamethasone orally for 2 days, 5 patients suppressed after 8 mg dexamethasone administration, and 1 patient with CRF resisted suppression. Hemodialysis did not alter mean 24-h cortisol levels or numbers of secretory episodes but produced a shift of secretory activity into the dialysis time period. These studies show alterations in cortisol dynamics in which increased plasma cortisol levels and dexamethasone resistance coexist with normal circadian rhythmicity.

Study of a kindred with thyroxine-binding globulin deficiency and oligomenorrhea.

The finding of a low total thyroxine level in an oligomenorrheic woman uncovered a new family with thyroxine-binding globulin deficiency and oligomenorrhea. Thirteen of 17 family members had the deficiency of thyroxine-binding globulin, with heterozygous female subjects showing overlap of levels with normal subjects. Oligomenorrhea was frequently found but segregated separately from the thyroxine-binding globulin deficiency; of seven women with low levels, three had normal monthly menstrual cycles. Fertility was not impaired.